Advncd care plan 30 min
CPT 99497 covers the first 30 minutes a physician or qualified healthcare professional spends with a patient discussing future medical decisions, including end-of-life preferences, treatment goals, and advance directives.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Always document start and stop times for the advance care planning discussion to support time-based billing (minimum 30 minutes required)
Impact: Missing time documentation is the leading cause of denials; proper time stamps can secure the full $79.57 payment versus denial
Append modifier 33 to 99497 for all Medicare patients to designate as preventive service and eliminate patient cost-sharing
Impact: Modifier 33 ensures $0 patient responsibility; omission results in 20% coinsurance charge ($15.91) to patient and potential complaints
Bill 99497 with modifier 25 when performed same day as separate E&M; ensure documentation clearly distinguishes the two services
Impact: Allows capture of both payments (E&M + $79.57); without proper separation, expect bundling denials and loss of ACP payment
Use add-on code 99498 for each additional 30 minutes beyond the first 30 minutes (pays $86.36 in 2025)
Impact: 60-minute ACP session should bill 99497 + 99498 for total payment of $165.93; undercoding loses $86.36 per hour-long session
Document specific advance directive forms discussed (living will, POLST, healthcare proxy) and patient/family questions addressed
Impact: Detailed content documentation withstands audits; vague notes like 'discussed goals of care' trigger medical necessity denials
Note whether patient has capacity or if surrogate decision-maker is present; document relationship if family member participates
Impact: Establishes medical necessity and appropriateness; improves audit defense and supports medical decision-making complexity
Common denials
Insufficient time documentation - missing start/stop times or documented time less than 30 minutes
How to appeal: Submit corrected claim with addendum to medical record clearly documenting start time, stop time, and total duration. Reference CPT guidelines requiring minimum 30 minutes. Include attestation statement if time was documented elsewhere in EHR.
Medical necessity denial - payer questions need for advance care planning service for this particular patient
How to appeal: Provide patient's diagnosis codes showing serious/chronic illness, age, recent hospitalization, or other clinical factors. Submit letter explaining why ACP was medically appropriate. Cite CMS policy that ACP is voluntary and not diagnosis-dependent.
Bundling denial when billed same day as E&M without modifier 25
How to appeal: Resubmit claim with modifier 25 appended to the E&M code. Include documentation showing ACP discussion was separately identifiable from the E&M service with distinct time periods and purposes documented.
Duplicate service denial - payer claims ACP was already provided within a certain timeframe
How to appeal: Medicare does not limit frequency of 99497, but document reason for repeat discussion (change in health status, patient request to modify directives, new diagnosis). Include notes showing different content or updated preferences discussed.
Frequently asked questions
How much does Medicare pay for CPT code 99497 in 2025?
Medicare pays $79.57 for CPT 99497 in non-facility settings and $72.46 in facility settings under the 2025 Physician Fee Schedule. The code has 2.46 total RVUs (1.5 work RVU, 0.86 non-facility PE RVU, 0.1 MP RVU).
Can CPT 99497 be billed with an office visit on the same day?
Yes, CPT 99497 can be billed with an E&M service on the same day if the advance care planning discussion is separately identifiable. Append modifier 25 to the E&M code and ensure documentation clearly distinguishes the two services with separate time documentation for each.
How many minutes are required to bill CPT 99497?
CPT 99497 requires a minimum of 30 minutes of face-to-face time spent on advance care planning discussion. You must document start and stop times. For additional 30-minute increments beyond the first 30 minutes, use add-on code 99498.
Does CPT 99497 require a copay for Medicare patients?
No, when modifier 33 is appended to CPT 99497, Medicare covers it as a preventive service with no copay or coinsurance. Without modifier 33, patients may be charged 20% coinsurance. Always append modifier 33 for Medicare beneficiaries.
Who can bill CPT code 99497?
CPT 99497 can be billed by physicians, nurse practitioners, physician assistants, and clinical nurse specialists. The service must be performed directly by the qualified healthcare professional; it cannot be billed incident-to or performed by clinical staff under supervision.
Is there a limit to how often CPT 99497 can be billed?
Medicare does not impose frequency limitations on CPT 99497. It can be billed multiple times per year as long as each service is medically necessary and properly documented. Document reasons for repeat discussions such as change in health status, updated preferences, or new diagnoses.
What is the difference between CPT 99497 and 99498?
CPT 99497 covers the first 30 minutes of advance care planning and is the primary code. CPT 99498 is an add-on code for each additional 30 minutes beyond the first 30 minutes and cannot be billed alone. A 60-minute session would be coded as 99497 + 99498.